Opioid Detoxification

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Opioid Detoxification

In this article

This article summarises the guidance on opioid detoxification from the drug misuse and dependence guidelines jointly produced by the Department of Health, the Scottish Government, the Welsh Assembly Government and the Northern Ireland Executive (last updated in September 2007),[1] as well as the National Institute for Health and Clinical Excellence (NICE) guidelines on opioid detoxification for drug misuse.[2] It should be read in conjunction with the separate overview article Drug Misuse and Dependence: UK Guidelines.

Detoxification is indicated for patients who wish to become drug-free (as opposed to maintenance, which is indicated for patients who wish to reduce their use but are not ready to come off opioids completely.

GPs providing care for patients undergoing detoxification regimes should do so in close co-operation with drug clinic workers and pharmacists. The degree of involvement of the GP will depend on their experience and training; GPs with a special interest may be confident in initiating detoxification regimes with minimal specialist involvement.[3]

Introduction

Opioid detoxification should be offered in an appropriate setting to informed opioid-dependent patients ready for, and committed to, abstinence.[2]

Suitability for detoxification should be determined during the assessment process.

The aim is for safe and effective discontinuation of opiates and minimal withdrawal symptoms.

Detoxification usually takes about 28 days as an inpatient and up to 12 weeks in the community.

NICE recommends that a community-based programme should be routinely offered. However, it does suggest that exceptions to this may include:

Those who have had previous unsuccessful community detoxification.

Those who need medical and nursing care due to significant mental or physical health problems.

Those who require complex polydrug detoxification.

Those who have significant social problems that may limit the success of community-based detoxification.

If detoxification is unsuccessful, patients should have access back into maintenance and other treatment.

Suitability for detoxification

Is the patient committed and fully informed about the detoxification process?[2]

Does the patient understand the physical and psychological aspects of opioid withdrawal and how they can be managed?

Does the patient understand how non-pharmacological approaches can help with withdrawal symptoms?

Does the patient understand the increased risk of overdose and death after detoxification if illicit drug use resumes (due to the loss of opioid tolerance; increased risk if alcohol and benzodiazepines are also used)?

Has the high risk of relapse been explained to the patient?

Are adequate social support networks available following detoxification?

Is there availability of continuing professional support and treatment to maintain abstinence?

Drugs used in detoxification

Use the drug on which the patient has been stabilised. NICE states that there is no evidence that methadone or buprenorphine differs in its effectiveness during detoxification and recommends that they can both be used as first-line.[5] NICE does not support the use of ultra-rapid detoxification under general anaesthetic or sedation because of the risk of serious adverse effects.

GPs prescribing methadone or buprenorphine should do so in instalments using FP10 (MDA) in England and Wales or GP10 (3) in Scotland, initially daily.[3] For more information on writing prescriptions for controlled drugs in general practice see separate Controlled Drugs article.

The Royal College of General Practitioners (RCGP) warns that several missed doses may mean a loss of tolerance to opioids. If three days are missed consecutively a dose review and possible reduction in dose should be considered. If five or more days are missed consecutively, re-assessment and re-induction should be considered.[3]

Naltrexone is an opioid antagonist. It can block a former opiate user from experiencing the effects of opiates when taken regularly. Therefore, it can be helpful in maintaining abstinence following detoxification.

Article Information

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